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Posts Tagged ‘hormones’

Itchy beyond words. Crotch of underwear rubs painfully against labia. Sensation of being on the receiving end of a vulvar wedgie. Feels like tiny razor blade nicks in my vagina during intercourse without lube or adequate foreplay. Also difficulty with penetration.

Doesn’t that sound awful? If that were you, I wouldn’t be surprised that you’re not thinking about sex. Just as awful, about half of us think that vaginal dryness is something we just have to live with—and about the same number of us are hesitant to raise the topic with our doctors.

The truth is that vaginal dryness does not need to end the intimacy you have with your partner—or the afterglow you experience yourself after sex.

First, a word about what’s happening: Yes, it’s likely hormones. As estrogen levels decline, the vaginal lining changes. It becomes more delicate and less stretchy. There’s less lubrication and less circulation. Vaginal dryness is a typical first sign of vaginal atrophy, when vulvo-vaginal tissues shorten and tighten. It’s common; you’re not alone, and you’re not deficient.

If you’re just beginning to notice some discomfort, you can take the easy step of adding lubricant to your foreplay. Lubricants come in three types: water-based, silicone, and hybrid. My patients with dryness issues typically like the silicone and hybrid best, because they last the longest without reapplication, and because they seem just a little bit slipperier to some. Lubricants are made specifically for safe use on and in your vagina; if you want to experiment with a few, you can try our Personal Selection Kit (and read more about it here).

Next, you can add a vaginal moisturizer. While lubricants provide temporary comfort, reducing friction during sex, moisturizers work to “feed” and strengthen vaginal tissues around the clock. Moisturizing here is just like moisturizing your neck or your face: You have to be faithful! I recommend application at least twice a week. Moisturizers need to be placed directly in your vagina, which can be done with an applicator or a clean syringe you reserve for that purpose.

For some women, these two products—and the right amount of foreplay—are enough to make a difference. If they don’t do it for you, please talk to your health care provider, even if you think it will be awkward: Your sex life is important! There are localized estrogen products and a relatively new oral medication (called Osphena) that may be helpful for you, but you’ll need a consultation with your physician and a prescription.

This isn’t the end; it’s only a transition, which we as women have a lot of practice with. Take heart and take charge!

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Recently, I was browsing through an online discussion board about the pros and cons of hormone replacement therapy. I ran across this comment from a participant: “I’m going to try bioidentical hormones like Suzanne Somers. I’ve heard they’re safer.”

Whoa! I thought. Let’s do some objective homework first, and weigh the risks before you jump in.

Celebrity endorsements notwithstanding, bioidentical hormone replacement therapy (bHRT) is neither the miracle cure nor fountain of youth touted by Ms. Somers. Nor is it some kind of snake oil concocted by salacious quacks or unscrupulous doctors and pharmacists.

The truth is, of course, much more nuanced.

As a physician, I’d always opt for more treatment choices when it comes to helping women with the unpleasantries of menopause. I want more drugs in the arsenal, more ways to treat hot flashes, sleeplessness, and loss of libido. However, the entire topic of bioidentical hormones is so laden with emotion and misinformation that it takes a very fine point to tease fact from hyperbole.

We laid the groundwork on bioidenticals before, but the issue continues to befuddle and mislead, so let’s circle back and fill in some gaps.

Any hormone therapy, whether bioidentical or synthetic, is only intended to ease menopausal symptoms. Hormones were never meant to keep your memory sharp or your hair shiny or your skin taut. Hormones are not a fountain of youth. The latest medical guidelines state that hormones should be taken at the lowest possible dose for the shortest period of time needed to ease symptoms. This is because hormones, whether bioidentical or synthetic, are drugs and they interact with other systems in the body, sometimes in ways that are not well understood.

Point #1. Menopause isn’t a disease; it’s a natural transition. Hormone therapy is intended neither to keep your hormones “in harmony” nor to keep menopause at bay indefinitely. Hormone therapy is intended to ease the symptoms of the menopausal transition when they are interfering with your life.

Next, bioidenticals aren’t necessarily “natural” and therefore “safer.” The marketing message that hooks women is that bioidentical hormones are derived from “natural” sources and are therefore safer than hormones from other sources.

Bioidenticals are estrogens that are indeed made from plant sources, but they are processed (synthesized, if you will) to create a hormone that can be absorbed by humans. “All plant-derived hormone preparations, whether they come from a compounding pharmacy or a large commercial pharmacy, require a chemical process to synthesize the final product,” writes Dr. Oz in this article.

With bioidenticals, however, you end up with a molecule that is exactly like (identical to) human hormones, whereas non-bioidentical hormones are similar but not identical.

Any hormone, whether those your body produces or those you ingest, affects your body. Also, the delivery method, whether a patch, pill, or vaginal cream, also affects the way your body absorbs and responds to the hormone.

Point #2: Don’t equate “bio” with something “natural” and therefore risk free. Taking any hormone involves some risk. (Decisions about hormone therapy need to be based on careful consideration for each individual—understanding both the potential risks and benefits for that woman.) Bioidentical hormones are so-called because the molecule is identical to the human hormone and because they are derived from plant sources, even though they must be synthesized to be useful.

“So ‘natural’ doesn’t necessarily equal ‘safe’—and may simply be a euphemism for ‘unregulated,’” according to this article in the Harvard Women’s Health Watch.

You can, we should note, get bioidentical hormones that are FDA approved and regulated. Many familiar brands of hormonal rings, creams, patches, pills, and gels are both commercially manufactured by pharmaceutical companies and bioidentical. These include Estrace, Femring, Vivelle, Vagifem, and Prometrium, and more.

You know what you’re getting with these products. You know that the active ingredient is in the form and dosage that the label says it is. That kind of uniformity and “safety” is the assurance provided by FDA testing and approval.

Point #3: Many major brands of commercially manufactured hormones are both bioidentical and FDA approved.

Next, let’s understand what “custom-compounding” means. Many bioidenticals are touted as natural, safe, and custom-made just for you to bring your hormones back in balance. Custom-compounded drugs are made in small, customized batches by pharmacies that specialize in custom-compounding. They can be prescribed by a clinician.

Custom-compounding is very helpful when a patient needs a special dosage of a medication, or a different delivery method, or is allergic to a filler in a commercial drug. Maybe, for example, you need a lower dose of progesterone than is commercially available, or you need it in a vaginal cream, and the big pharmas only make it for administering orally.

However, neither the process nor the product is FDA-regulated or approved, and in fact, studies have shown that they are much less consistent than commercial products. In a few highly publicized cases, contaminated medications distributed by custom-compounders have been responsible for serious illness, infection, and death. An example is the outbreak of fungal meningitis in the fall of 2012.

The problem with custom-compounded hormones arises with claims of customized products that are safe, natural, and that will restore hormonal balance, among other things.

In actuality, it’s not possible to accurately pinpoint hormonal levels in an individual because they are constantly changing. The hypothalamus, pituitary and ovaries (the HPO axis, as we call it) work in a very integrated and precise way to direct hormone production. Our replacements aren’t able to replicate that concert of events, but we can do a good job of replacing the hormones more consistently, which many women prefer to the ‘ups and downs’ we’re familiar with. The only way to determine an effective dose is through symptom control—the lowest dose that relieves a woman’s symptoms. “Salivary and blood testing of hormone levels used by custom compounders is meaningless for midlife women as their hormone levels vary throughout the day, and from day to day” is the North American Menopause Society position.

“This doesn’t mean that you shouldn’t consider compounded hormones. Just realize that, in a real sense, you’re going to be an experiment of one,” says the Harvard Medical Watch article.

Also realize that custom-compounded drugs usually aren’t covered by insurance, and the regimen of testing and compounding gets expensive very quickly.

Point #4. Custom-compounding of drugs is a time-honored practice of making drugs in small batches or according to specific needs (while the processes and products aren’t subject to federal regulation or oversight). Claims that these products are healthier, safer, or somehow contain properties lacking in commercial products should be viewed with suspicion.

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Many women go through menopause with little more than irritability and hot flashes. In our last blog post, we reviewed research that suggests, though, that if you’ve experienced postpartum depression or hard-core premenstrual syndrome, you may be at higher risk for depression during perimenopause or menopause. Awareness and perhaps some preparation for this challenging transition might be prudent. It’s like an athlete training for a race. You want to be in shape before you hit the tarmac.

And even if you’ve never had a down day in your life, some commonsense lifestyle adjustments as you approach your “window of vulnerability” might ease the transition. What you absolutely do not want is to be taken by surprise at the intensity of your emotions, as this couple, tragically, was.

Forewarned, as they say, is forearmed.

So here are some suggestions for greater awareness and healthy lifestyle changes that, honestly, are never too late (or early) to adopt:

Nutrition. Eating sensibly is a good foundation for the inevitable metabolic changes that happen during menopause. Go heavy on whole grains and fresh fruits and veggies, ideally from local, organic sources. Lighten up on fats and sugar. Take your vitamins.

If you need to lose some serious weight, now’s the time to get serious about it, before menopausal changes really kick in.

Get moving. Lack of social connection and daily activity intensifies a sense of isolation and lethargy. Create a routine of exercise and involvement. Volunteer for a few organizations you believe in or enjoy. Exercise regularly. Get outdoors—don’t just walk from house to car. Surround yourself with healthy activity and people you like.

Explore treatment options. Some studies indicate that, for perimenopausal depression, hormone replacement therapy, sometimes in conjunction with antidepressants, can ease the mood swings, hot flashes, and insomnia, especially during the early stages of menopause.

St. John’s wort may also relieve mood swings and anxiety during menopause. (But don’t take any natural remedy without talking to your doctor first.)

Build your network. It’s comforting to know that people you trust have your back. And it’s a lot easier to find helpers before you’re in the thick of things.

Maybe find a therapist you like. Maintain connections with good friends.

And if you find yourself overwhelmed with feelings of unworthiness, or are unable to get out of bed or to function normally, for heaven’s sake, tap into that support system. Call your therapist or doctor. Call someone you love.

Menopausal depression is treatable and usually resolves itself once you’re through the change. Then you’ll be back to your sunny, even-keeled self.

In the meantime, it’s just your hormones talking.

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We’ve talked about depression during menopause. It’s a common, joy-sapping beastie that rears its ugly head during this time of whacked-out hormones and middle-age adjustment.

After all, what with hot flashes, insomnia, loss of libido, mood swings, who wouldn’t feel depressed?

While we may not exactly sail through menopause, most of us make it through “the change” relatively unscathed. But for a few, the hormonal fluctuations that may precede menopause by a number of years is part of a larger picture—sort of a déjà vu experience that we ought to be aware of so as not to be blindsided by it.

Episodes of depression are common, and they are more common for women than for men. About 20 percent of women—one in five—will experience major depression at some point in life, and that’s twice the rate at which men become depressed, according to this report in “Dialogues in Clinical Neuroscience.”

Why this happens is unclear, but one obvious culprit is the normal hormonal fluctuations that occur at predictable points in a woman’s life: puberty, menstrual cycles, childbirth, and menopause. Some women appear to be more sensitive to these hormonal changes, and depression—sometimes crippling in its intensity—can result. These predictable points at which female hormones are on a roller coaster may be considered “windows of vulnerability.”

Perimenopause—the years immediately preceding active menopause—seems to be the point at which depressive episodes are more frequent. Even before a woman’s menstrual cycle is changing, her hormones may be dancing the rhumba. Perimenopause can last for five years, on average, and 95 percent of women enter it between the ages of 39 and 51.

“These periods are not only marked by extreme hormone variations but may also be accompanied by the occurrence of significant life stressors and changes in personal, family, and professional responsibilities,” writes researcher Claudio Soares in this report for Biomedcentral.com.

The thing to be aware of, however, is that the biggest predictor of perimenopausal or menopausal depression is a prior episode of depression. And the “reproductive life cycle event” most strongly correlated with perimenopausal depression is postpartum depression—the “baby blues.”

“We also found, however, a correlation between perimenopausal mood ratings and ratings at other reproductive cycle events, especially between perimenopausal depression and postpartum depression,” write the authors of this study published in the Journal of Clinical Psychiatry. “This suggests that there may be a subgroup of women who have a specific vulnerability to developing reproductive cycle event–related depression.”

Other well-regarded studies have confirmed these correlations.

What this means for you, as you head into your final and very challenging “reproductive life cycle event,” is that if you’ve experienced postpartum depression or hard-core premenstrual syndrome, you may be at higher risk for depression during perimenopause or menopause.

In fact, if you’ve had one prior incident of depression, your chances of having another are one in two (fifty percent). If you’ve had three previous depressive episodes, your likelihood of experiencing another is 95 percent, according to The Massachusetts Health Study cited in this report.

But that doesn’t mean you’re without resources: Forewarned, as they say is forearmed. In our next blog post, we’ll talk about what you can do to increase awareness and keep yourself healthy—in body, heart, and mind.

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Can’t remember the name of the new work colleague? Forgot the city your best friend lives in? Can’t recall the movie you saw last week?

Join the club.

A little-known fact about loss of estrogen is that it takes a bit of memory with it when it goes. That’s why memory decline is a common feature in post-menopausal women.

Insult to injury, if you ask me. Let’s face it, at this stage of the game, we can ill-afford to lose any bit of that precious function.

In a new study, however, Australian researchers have found that small daily doses of testosterone gel applied to the upper arm improved verbal memory in postmenopausal women.

Testosterone is an androgen—a male hormone—that governs all kinds of things in men, especially sex drive.

Women produce testosterone, too, in the ovaries and adrenal glands, but in miniscule amounts, and its function is not well understood. Testosterone levels drop quickly as women age until at age 40 a woman usually has about half the level of a 20 year old.

It affects libido and has been used successfully to treat low sexual drive in women, but its long-term effects—or even correct dosages—haven’t been rigorously studied.

Testosterone treatment for women hasn’t been approved in either the U.S. or Canada, so it has to be prescribed “off-label.” That means either the physician prescribes an FDA-approved male pharmaceutical product in very small doses (usually about one-tenth of dose recommended for men) or the hormone is compounded specially by a pharmacist.

In the Australian study, researchers found an intriguing link between verbal memory and testosterone in women. In the study, 92 post-menopausal women (between 55 and 65) were first given standard tests for cognitive function. Then they were randomly assigned to receive either a placebo or dosages of testosterone gel for 26 weeks.

At the end of the treatment period, the women receiving testosterone had higher levels of the hormone in their system, and they scored 1.6 times better in tests of verbal memory (recalling words from a list). Scores on other tests remained the same between the two groups.

While these results aren’t game-changers, they do represent one of those incremental steps that can lead to significant advances. “This is the first large, placebo-controlled study of the effects of testosterone on mental skills in postmenopausal women who are not on estrogen therapy,” said Dr. Susan Davis, principal investigator in the study.

Since there is currently no treatment for memory loss, and since women suffer from dementia in greater numbers than men, this link between testosterone and memory could be an important finding.

Not to mention the potential side effect of improved libido.

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It’s no wonder we’re confused. First it’s good; then it’s bad. Now it’s up to you.

Hormone replacement therapy has had more media makeovers than Liz Taylor, and it continues to grab attention here and there.

The latest, and highly credible, statement on the issue is from an international roundtable of medical experts convened by the Society for Women’s Health Research (SWHR). The purpose of this gathering of experts, which represented various specialties, such as cardiovascular disease, osteoporosis, and cancer, was to take yet another objective and rigorous look at the evidence regarding hormone replacement therapy, and to make recommendations as to its use and safety. The results of this discussion just came out in the Journal of Women’s Health.

This roundtable is a good effort to shed some objective light on the risks and benefits of an issue that’s been hotly debated for over ten years now, ever since the Women’s Health Initiative (WHI) prematurely ended its groundbreaking study of women receiving hormone therapy in 2002 because of a high incidence of breast cancer and cardiovascular complications.

The problem, however, is that hormone therapy (HT) is still the only effective, FDA-approved treatment for menopausal symptoms, such as hot flashes and vaginal changes. Recently two non-hormonal drugs were just nixed by an FDA advisory panel because they were viewed as ineffective.

Ever since the WHI results were released, the pendulum has been swinging wildly with each new medical release or research report. And while this latest SWHR roundtable really moves the chess pieces very little, it does solidly reaffirm positions held by the North American Menopause Society.

(In fact, NAMS had released its latest position statement on hormone treatment barely a month earlier.)

What the roundtable did add, however, is something I strongly advocate: Give women solid information about their treatment options and let them make informed decisions about their own health.

Their findings include:

  • In younger, postmenopausal women with menopausal symptoms, the benefits of HT outweigh the risks;
  • HT is the most effective treatment for osteoporosis and should be considered for the prevention of osteoporosis, especially among at risk women;
  • Contrary to popular misconceptions, HT for early, postmenopausal women does not increase the risk for coronary heart disease (CHD) and may even reduce it;
  • HT does not increase total mortality rates and may, in fact reduce them.

Here’s how the SWHR roundtable puts it: “It’s time to put HT back on the table so that women can discuss with their providers the option of symptom relief and possible long term health benefits.”

Amen to that.

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Whether you’re using a cream, tablet, or ring to add localized hormones to your vagina, your partner is not absorbing any—no more than he did when you were producing your own hormones before menopause. You (and he!) can feel perfectly confident about your use of these products, and your intimacy will benefit from the increased comfort you’re likely to experience.

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A burning sensation in the vaginal and vulvar area can be a symptom of vulvovaginal atrophy, which occurs as estrogen levels decline. Premarin cream or other localized estrogen can reverse those atrophic changes; it typically takes weeks of use for full effect.

If the burning sensation is in or extends further back, toward or including the buttocks, it’s likely not vulvovaginal atrophy. It could be, instead, a nerve condition. Shingles, unfortunately, can happen in this area; there are other pelvic floor conditions—like scarring or injury—that can affect nerves. A careful pelvic exam can help to determine exactly what’s happening.

I encourage you to talk to your health care provider—and again, if you’re not seeing improvement!

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Most women have very normal sexual function without a cervix. I have seen reports that suggest an issue, but in 24 years of practice, I can’t recall a single woman who was impaired by the absence of her cervix.

There are complications that result if the cervix is left after a hysterectomy, including abnormal pap smears and continued bleeding. If there is any remaining endometrium (the membrane lining of the uterus) and you consider hormone therapy in menopause, you will need progesterone as well as estrogen. I’ve seen women less fond of progesterone than estrogen.

Whether you’re able to keep ovaries in a hysterectomy is a bigger issue to sexuality—and in fact overall health—for women. Even after menopause, the ovaries continue to produce hormones. Those hormones not only mitigate some of the effects of menopause, but they also promote bone and heart health. There are times when it’s appropriate to remove the ovaries as part of a hysterectomy, but the decision needs to be made based on each woman’s health and history.

Glad you’re thinking about your continued sexual health, and good luck with your recovery!

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Yeah, I know. You’ve been doing the contraception shuffle for, oh, decades now. Isn’t it “safe” yet? After all, you’re past 40. Maybe you’ve even missed a couple periods.

Not so fast.

You’re in the midst of a very hazardous crossing—those uncertain years between fertility and menopause during which you are less likely to get pregnant, but, make no mistake, you still can!

While women are indeed less fertile after 40, they absolutely can get pregnant. In fact, women can conceive even during perimenopause, when the menstrual cycle is beginning to become irregular.

For some reason, however, women seem to become more casual as they near the goalposts. How else to account for the fact that women over 40 are the least likely to use birth control of any age group, and that their abortion rates are as high those of adolescents, according to a 2008 USA Today article.

In Great Britain, women in their 40s are now called “the Sex and the City generation,” and they, too, have grown careless. In the UK, abortions within the over-40 age group have risen by one-third in the past decade. In the US, 38 percent of pregnancies in women age 40 and older are unplanned. Of those, 56 percent end in abortion, according to this article in HealthyWomen.org.

By the time they reach 40, women are generally old hands at birth control. But at this point in life some reevaluation may be in order. Levels of fertility are decreasing, and hormonal levels are (or soon will be) in flux. Some women may not want to have children; others may want to keep the option open. In any case, an unplanned surprise complicates life really fast.

This is a good time for a conversation about birth control with your healthcare provider, and you may have to initiate it. While you have more options than ever, the best one for you might be different than what worked for you in your 20s.

And just so you know, current guidelines advise that you remain on birth control until one year after your last period, the official definition of menopause. Complicating the picture is the fact that with hormonal forms of birth control, such as the pill, your cycles may be irregular or may stop completely, which masks the onset of menopause. And the withdrawal bleed during the week off the pill isn’t considered a true period.

Birth control after 40 falls into several categories: permanent, long-term or short, hormonal or barrier method. They vary in levels of effectiveness and in the side effects you may experience. And remember that condoms are the only type of birth control that protects against sexually transmitted infections.

Probably your most immediate decision is whether to end childbearing permanently. Tubal ligation is a laparoscopic procedure that happens under general anesthetic in a hospital. There’s also a new, non-surgical option that a doctor can do with a local anesthetic right in the office.  Or, of course, your partner could have permanent sterilization as an outpatient office procedure.

Hormonal types of birth control are very effective, but can have both side effects (bloating, risk of stroke for some women) as well as protective benefits (against bone loss and some forms of cancer, for example).  It is very important to carefully review your health history with your health care provider to select the best option for you.

Short-term hormonal options include

  • Combined estrogen-progestogen pill (COCP). This is “the pill” you are probably familiar with. Since it now has very low estrogen levels, it’s considered safe for women who have no risk factors until age 55.
  • Progestogen-only pill (POP), which is a good option for older women. It must be taken regularly at the same time of day, however.

Long-term hormonal options include

  • Progestogen shot, which is a once-every-8-12-week option.
  • Progestogen implant, in which a tiny rod is inserted in the upper arm. It lasts for three years.
  • Vaginal rings release low dosages of estrogen. The ring is kept in the vagina for three weeks, then removed for a week.
  • A patch, which also releases low dosages of estrogen and progestogen.
  • An IUD impregnated with progestogen, which is highly effective and lasts for years.

The old non-hormonal standbys still include

  • Condom. Again, the only birth control that also protects against STIs.
  • Non-hormonal IUD. Also highly effective and long-lasting.
  • Diaphragm with spermicide, cervical cap, or spermicidal sponge.

Your choice of birth control at this point should be informed and careful. You need a plan to carry you through menopause, and you need to begin the dialog with your healthcare provider.

Since the consequences of ignoring the issue are so life-changing, this conversation ought to begin now!

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